Hey this is Dr K from imedicalschool and today we are going to talk about systemic lupus
erythematosis otherwise known as SLE.
So as the name suggests SLE is a systemic autoimmune disorder that causes inflammation
and affects all the major organs of the body.
If you are interested in learning what you can do to help further lupus research or support
advocacy for lupus patients make sure to check out the Lupus Foundation of America at lupus.org.
Since lupus is a systemic inflammatory disorder what are the symptoms of lupus?
Well lupus commonly presents with a multitude of generalized symptoms making the differential
diagnoses quite broad.
Some common general symptoms include fever, fatigue, myalgias, arthritis, and weight loss.
There are additional symptoms and signs associated with lupus and we will talk about them next
as we discuss how to diagnoses lupus.
The most important step in understanding any disease is grasping how to diagnose the disease.
Lets talk about how to diagnose lupus.
There are many pneumonics that can aid in remembering all the diagnostic criteria.
The one I remember is called DOPAMINE RASH.
You need to have at least 4 criteria met to diagnose lupus.
Lets go through each one.
The D represents discoid rash.
A discoid rash is a disc shaped rash that is flat but has pronounced redness at the
borders.
Here we have a picture that demonstrates a discoid rash.
Next we have oral ulcers.
Generally patients will have ulcers that you find incidentally on exam.
The way to differentiate these ulcers from infectious ulcers is that infectious ulcers
are usually painful while ulcers from lupus are generally painless.
Other skin findings include a photosensitive rash.
Photosensitive means that sun exposure triggers and can worsen the skin rash.
Patients do not need much sun exposure to really develop these rashes.
In addition patients may experience joint pain otherwise known as arthralgia or joint
inflammation known as arthritis.
A classic physical exam finding for a lupus patient is the Malar rash.
The Malar rash affects the cheeks and the bridge of the nose.
In a truly classic rash it appears in the shape of a butterfly covering the nasal bridge
and both cheeks.
In addition to rashes another criteria is immunologic phenomenon.
Immunologic phenomenon include detection of anti-smooth muscle antibody, anti-double stranded
DNA, ant-Ro and anti-La (otherwise known as SSA and SSB.)
Finally if the lupus is drug induced you may see anti-histone antibodies.
The next criteria are neurologic phenomenon.
Patient can develop altered mental status, seizures, stroke and headache.
In addition to mental status changes lupus can damage the kidneys causing either a nephritic
or a nephrotic disorder.
Nephritic disorder is when the kidney is damaged causing proteinuria with less than 3.5 g/day
in the urine. in addition in a nephritic disorder a patient may have high blood pressure and
RBC casts.
Nephrotic disorder is when there is significant protein loss of greater than 3.5 g/day in
the urine.
In addition patients have elevated cholesterol levels, low albumin levels, and edema.
One of the classical tests for lupus is ANA or antinuclear antibody.
ANA is sensitive but not specific so a positive ANA alone does not indicate lupus and you
need to look for other criteria described by DOPAMINE RASH to make the diagnosis.
Other symptoms are characterized as serositis.
This includes pleuritis, pericarditis, and peritonitis.
Finally patient can have hematological phenomenon.
These include anemia, thrombocytopenia, and hemolytic anemia.
Now that we have talked about the diagnostic criteria for lupus lets talk about how to
monitor disease activity.
Lupus patient will need frequent routine labs to monitor disease activity.
Key labs include C3, C4, and CH50.
These labs test the complement system.
When lupus is highly active it leads to consumption of complement factors.
In addition a rise in the IgG anti-double stranded DNA indicates an increase in disease
activity.
In addition to monitoring disease activity, as we know, lupus can cause kidney damage.
One indicator of proliferative glomerulonephritis is a drop in C1q complement.
The next important step is treatment of lupus
One of the most important factors in decreasing disease activity is to stop smoking.
Smoking has been linked to worsening disease activity and worse outcomes.
Like I mentioned before lupus patients should be monitored with frequent labs.
These labs include CBC, ESR, CRP, urinalysis, spot urine and creatinine, CH50, C3, C4, and
anti double stranded DNA.
In terms of actual therapy the first step is to begin with NSAIDs.
If NSAIDs do not control symptoms, and they rarely do, hydroxychloroquine can be used.
Hydroxychloroquine is an antimalarial medication and has been shown to prevent damage to the
central nervous system and kidneys.
If symptoms continue to persist and major organs are being affected systemic corticosteroids
should be administered.
Finally if these therapies do not work the patient needs to be escalated to methotrexate,
cyclophosphamide, and azathioprine for better system control.
Well that was a brief review of systemic lupus erythematoisis.
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This is Dr K from imedicalschool and I will see you next time.